I have read the journal's policy and the authors of this manuscript have the following competing interest: CB reports grants and personal fees from Acadia pharmaceutical company, grants and personal fees from Lundbeck pharmaceutical company, personal fees from Napp pharmaceutical company, personal fees from Roche pharmaceutical company, personal fees from Orion pharmaceutical company, personal fees from Bial pharmaceutical company, personal fees from Bristol Myer Squibb pharmaceutical company, personal fees from Otusaka pharmaceutical company, personal fees from Novartis pharmaceutical company, personal feees from Sunovion, outside the submitted work; AC reports personal fees from Lundbeck, personal fees from Novartis, personal fees from Bial, personal fees from Acadia, personal fees from Sunovion, outside the submitted work; MO, JF, JW, EMC, BW, AC and CB report grants from NIHR, during the conduct of the study. All other authors have nothing to disclose.
Agitation is a common, challenging symptom affecting large numbers of people with dementia and impacting on quality of life (QoL). There is an urgent need for evidence-based, cost-effective psychosocial interventions to improve these outcomes, particularly in the absence of safe, effective pharmacological therapies. This study aimed to evaluate the efficacy of a person-centred care and psychosocial intervention incorporating an antipsychotic review, WHELD, on QoL, agitation, and antipsychotic use in people with dementia living in nursing homes, and to determine its cost.
This was a randomised controlled cluster trial conducted between 1 January 2013 and 30 September 2015 that compared the WHELD intervention with treatment as usual (TAU) in people with dementia living in 69 UK nursing homes, using an intention to treat analysis. All nursing homes allocated to the intervention received staff training in person-centred care and social interaction and education regarding antipsychotic medications (antipsychotic review), followed by ongoing delivery through a care staff champion model. The primary outcome measure was QoL (DEMQOL-Proxy). Secondary outcomes were agitation (Cohen-Mansfield Agitation Inventory [CMAI]), neuropsychiatric symptoms (Neuropsychiatric Inventory–Nursing Home Version [NPI-NH]), antipsychotic use, global deterioration (Clinical Dementia Rating), mood (Cornell Scale for Depression in Dementia), unmet needs (Camberwell Assessment of Need for the Elderly), mortality, quality of interactions (Quality of Interactions Scale [QUIS]), pain (Abbey Pain Scale), and cost. Costs were calculated using cost function figures compared with usual costs. In all, 847 people were randomised to WHELD or TAU, of whom 553 completed the 9-month randomised controlled trial. The intervention conferred a statistically significant improvement in QoL (DEMQOL-Proxy
These findings suggest that the WHELD intervention confers benefits in terms of QoL, agitation, and neuropsychiatric symptoms, albeit with relatively small effect sizes, as well as cost saving in a model that can readily be implemented in nursing homes. Future work should consider how to facilitate sustainability of the intervention in this setting.
ISRCTN Registry
In a cluster-randomized controlled trial, Clive Ballard and colleagues test whether a program combining staff training, social interaction, and guidance on use of antipsychotic medications improves quality of life and symptoms among people with dementia living in UK care homes.
People with dementia living in care homes often experience agitation and other symptoms that are difficult to treat and distressing for the individual.
We tested the WHELD programme, which combined staff training, social interaction, and guidance on use of antipsychotic medications, in 69 UK care homes in a 9-month clinical trial.
We showed that care homes receiving the WHELD programme saw improvements in quality of life as well as other important symptoms including agitation, behaviour, and pain in people with dementia.
The WHELD programme was also shown to be cost-effective.
The findings show that the WHELD approach is beneficial for people with dementia living in care homes.
WHELD could be provided in an affordable way to improve the lives of these individuals, who often do not receive the care they need.
There are 46.8 million people with dementia worldwide, many of whom reside in nursing homes. In the UK one-third of people with dementia live in care homes [
Neuropsychiatric symptoms affect 90% of people with dementia at some point during the course of their condition [
Livingston and colleagues [
Cost is a major consideration in the development and implementation of interventions in nursing homes [
The goal of this RCT was to evaluate the impact of the WHELD intervention on QoL, agitation, neuropsychiatric symptoms, antipsychotic use, global deterioration, mood, unmet needs, mortality, quality of interactions, pain, and cost in comparison to treatment as usual (TAU).
This study was a 9-month cluster-randomised controlled 2-arm trial conducted in 69 UK nursing homes between 1 January 2013 and 30 September 2015. There were 3 recruiting hubs based in South London, North London, and Buckinghamshire. Each cluster was randomised to receive either the WHELD intervention or TAU for 9 months. This research was reviewed and approved by the Oxford C National Research Ethics Committee (Ref: 13/SC/0281). This study is registered with the ISRCTN Registry (Ref: ISRCTN62237498). The full protocol is available in the published protocol paper [
Eligible nursing homes had at least 60% of residents with dementia. Nursing homes were excluded if they were receiving special support from their local authority or if they failed to meet the 5 Care Quality Commission care home quality standards. Within each participating nursing home, all residents were considered potentially eligible for inclusion if they met criteria for dementia (defined as a score 1 or greater on the Clinical Dementia Rating [CDR] [
The WHELD intervention consisted of a combination of elements taken from the interventions evaluated in a previous proof-of-concept study [
Training for staff was provided by a research therapist. Two lead care staff members (WHELD champions) were nominated in each care home. These individuals received additional training over a period of 4 months (1 training day per month) with further coaching, supervision, and regular review with the therapist over the 9-month period. The WHELD champions were responsible for the delivery and dissemination of the intervention in each care home. In addition, prescribing physicians were provided with educational materials about the intervention. The control group received TAU. The WHELD intervention is described in more detail in
All care home residents were assessed for dementia severity at baseline using the CDR [
All outcome measures were assessed prior to randomisation and after 9 months of the intervention by a trained research assistant. The assessments at follow-up were collected by research assistants who had not previously visited the participating care homes. The research assistants were blind to treatment allocation, and every effort was made to maintain the blind by minimising contact between the research assistants and research therapists, ensuring that WHELD champions were not informants, and giving clear instructions to care homes and the research team to not disclose treatment allocation. The primary outcome was QoL, measured by the DEMQOL-Proxy [
The secondary outcome measures included agitation assessed using the Cohen-Mansfield Agitation Inventory (CMAI) [
Economic data for each individual in the study were collected using an adapted version of the Client Service Receipt Inventory (CSRI) [
Nursing homes were allocated to receive either the WHELD intervention or TAU using secure web access to the remote randomisation centre at the North Wales Organisation for Randomised Trials in Health Clinical Trial Unit (NWORTH CTU) at Bangor University. Randomisation was performed by dynamic allocation [
Individual participants were consented and evaluated for dementia prior to randomisation of the nursing homes to minimise bias. Written consent was provided by participants when they had mental capacity to provide consent for their own participation. Written consent was provided by next of kin when individuals did not have mental capacity to consent for themselves. Clinicians and research assistants completing follow-up assessments were blind to treatment allocation. Every attempt was made to minimise accidental un-blinding by minimising contact between therapists and the researchers collecting outcome data and with clear instructions to researchers and nursing home staff to not discuss treatment allocation.
The target minimum sample size was 640 at the 9-month time point. Previous studies indicated that intra-home correlation coefficients rarely exceed 0.05. Taking this into account, a sample size of 640 participants therefore gives 90% power using a significance level of 5% to detect a standardised effect size of 0.3 SDs, which is generally accepted as the lowest threshold of a clinically meaningful benefit. The recruitment of a minimum of 840 participants allowed for loss of 200 through mortality or withdrawal, an important consideration in the context of the high morbidity and mortality of this group.
Outcome measures for the study were assessed at baseline and at 9 months. All the outcome measures collected were described and reported using appropriate descriptive statistics and tabular and graphical techniques. Means with 95% confidence intervals are quoted, and a 5% significance level is reported. The Consolidated Standards of Reporting Trials (CONSORT) diagram information is presented in order to identify any differential dropout between the arms of the trial. The analysis of the quantitative outcomes was undertaken using a multilevel analysis of covariance (ANCOVA).
The primary outcome measure (DEMQOL-Proxy) and the secondary outcome measures were analysed using the multilevel modelling approach to ANCOVA, with the value at 9 months as the response. The baseline value was the covariate. The key factor was group (treatment [WHELD] or control [TAU]). The multilevel nature of the design was represented by 2 levels: care home and individual residents in the care home. Other covariates were number of residents in each cluster and the age, sex, and severity of dementia (FAST stage—baseline and follow-up) of participants with dementia. The provisional analysis plan was developed based on the analysis model developed for a previous smaller factorial study of the WHELD intervention [
The same approach was used for the analysis of all secondary outcomes other than mortality, antipsychotic use, QUIS, and cost, except that the respective baseline variables were used as covariates rather than baseline DEMQOL-Proxy.
Mortality and antipsychotic use were compared between treatment groups using relative risk with 95% CI. QUIS used care-home-level data, and was compared between treatment groups using ANCOVA, but because of the smaller sample size did not use baseline covariates.
Further exploratory sub-group analysis was undertaken evaluating differences between WHELD and TAU in people with mild to moderate (FAST 4–5), moderately severe (FAST 6), and severe dementia (FAST 7) based on the recommendations of reviewers as part of the journal submission process. Based on reviewer recommendations, effect sizes and number needed to treat were also evaluated.
Total costs for each participant were derived from the collection of service use data for the 3-month period prior to the intervention (baseline) and the 9 months of the intervention (follow-up) and consisted of 3 main cost categories: intervention costs, accommodation charges, and health and social care costs. Intervention costs were calculated by deriving average hourly costs for WHELD champions and therapists, combined with time spent by each staff type on training, supervision, and intervention delivery, and were defined as a per participant cost. An additional cost was defined for the antipsychotic review element of the intervention for participants receiving antipsychotics. Accommodation costs were collected as weekly charges for each nursing home. Where this was unavailable or not known, the typical charge for a resident with a level of need similar to that of the participant in the study was obtained. Total health and social care costs consisted of services that are the main contributors to the cost of care in nursing homes: hospital inpatient, outpatient, day hospital, accident and emergency, primary care (calculated as per minute unit costs for general practitioners and practice nurses), community health care, and ambulatory care. Data on each nursing home resident’s use of health care (obtained from the CSRI) were multiplied by appropriate unit costs to calculate health and social care costs for each participant at each time point. Mean differences in costs and 95% CIs were obtained by non-parametric bootstrapped regression (1,000 repetitions) modelling to account for non-normal distributions. A multilevel mixed model was used, controlling for site and age at entry into the study. The adjusted total health and social care cost and outcome models also included the treatment variable as a random effect at the care home level. Clustering was accounted for by allowing the model intercept and treatment variable coefficient (i.e., treatment effect) to vary by care home.
As a sensitivity analysis, the same analysis was undertaken for the primary and key secondary outcomes but using imputed values for people who did not complete the 9-month follow-up. Logistic regression was used to predict missing variables from the factors and covariates measured at baseline, using the approach validated in a previous factorial study [
Data are deposited in the Dryad Digital Repository (doi:
In all, 1,006 participants were consented to the study, with 847 individuals randomised to TAU or WHELD. The majority of participants had moderately severe or severe dementia, and 71% were female. Follow-up assessments were available for 553 participants. Mortality accounted for the majority of participants who did not complete follow-up assessments. The descriptive statistics for participants who completed the follow-up were similar to those for the original population, although numerically marginally more residents receiving TAU completed the follow-up compared to those receiving the WHELD intervention (66.8% versus 63.6%). The baseline characteristics of the study participants are described in
CDR, Clinical Dementia Rating; TAU, treatment as usual.
Characteristic | Baseline cohort ( |
Completers ( |
||
---|---|---|---|---|
TAU | WHELD | TAU | WHELD | |
Male | 129 (29.1%) | 132 (32.7%) | 84 (28.4%) | 78 (30.4%) |
Female | 314 (70.9%) | 272 (67.3%) | 212 (71.6%) | 179 (69.6%) |
Mild dementia or less | 35 (7.90%) | 47 (11.64%) | 21 (7.09%) | 23 (8.95%) |
Moderate dementia | 38 (8.58%) | 39 (9.65%) | 15 (5.07%) | 16 (6.22%) |
Moderately severe dementia | 267 (60.27%) | 241 (59.65%) | 159 (53.71%) | 153 (59.53%) |
Severe dementia | 103 (23.23%) | 77 (19.06%) | 101 (34.12%) | 65 (25.29%) |
78 (9.2%) | 75 (8.9%) | 51 (9.2%) | 52 (9.4%) | |
103.84 (0.70) | 103.04 (0.74) | 103.69 (0.68) | 105.62 (0.59) | |
48.49 (1.03) | 48.29 (1.04) | 48.10 (1.06) | 46.00 (1.01) | |
2.13 (0.13) | 2.36 (0.23) | 2.14 (0.14) | 2.33 (0.24) |
Data are given as
CMAI, Cohen-Mansfield Agitation Inventory; FAST, Functional Assessment Staging Tool; NPI-NH, Neuropsychiatric Inventory–Nursing Home Version; TAU, treatment as usual.
The WHELD intervention conferred a statistically significant 2.54-point (SEM 0.88) improvement in QoL compared to TAU (95% CI 0.81, 4.28; Cohen’s
Outcome measure | Adjusted effect (SE) |
Mean difference (SEM) | 95% CI of mean difference | Effect size (Cohen’s |
Number needed to treat |
|
---|---|---|---|---|---|---|
DEMQOL-Proxy ( |
0.0042 | 2.54 |
0.81, 4.28 | 0.24 | 9 | |
CMAI ( |
0.0076 | 4.27 |
−7.39, −1.15 | 0.23 | 6 | |
NPI-NH ( |
<0.001 | 4.55 |
−7.07, −2.02 | 0.30 | 9 |
*Adjusted effect takes into account baseline value, age, sex, Clinical Dementia Rating, site, and clustering within care homes.
∆Based on binary outcome: better than mean overall outcome versus mean outcome or worse than overall mean outcome for DEMQOL and CMAI.
+DEMQOL: improvement in WHELD group from baseline to 9 months 4.78, improvement in TAU group 2.24, mean difference 2.54. CMAI: improvement in WHELD group from baseline to 9 months −4.13, worsening in TAU group 0.14, mean difference 4.27. NPI-NH: improvement in WHELD group from baseline to 9 months −2.64, worsening in TAU group 1.91, mean difference 4.55.
CMAI, Cohen-Mansfield Agitation Inventory; NPI-NH, Neuropsychiatric Inventory–Nursing Home Version; TAU, treatment as usual.
Prescriptions of antipsychotic medications were stable across the study in both treatment groups, with no reduction in antipsychotic use in the WHELD treatment group compared to TAU (change in antipsychotic use: WHELD −0.1%, SEM 0.1; TAU −0.2%, SEM 0.1,
The quality of interactions of positive care between care staff and residents with dementia (QUIS) was collected as a care-home-level assessment in 62 of the participating care homes. There was a statistically significant 19.7% greater increase in the proportion of positive care interactions from baseline to 9 months in the WHELD group compared to the TAU group (SEM 8.94; 95% CI 2.12, 37.16,
A sub-group analysis was also undertaken comparing the WHELD intervention in people with mild to moderate (FAST 4–5), moderately severe (FAST 6), and severe (FAST 7) dementia, focusing on the primary and key secondary outcomes (DEMQOL, CMAI, and NPI-NH). Statistically significant benefits of similar magnitude to the benefits in the overall population were seen in people with moderately severe dementia for QoL, agitation, and overall neuropsychiatric symptoms, but there were no statistically significant benefits on QoL in the smaller groups of individuals with mild to moderate or severe dementia. The full results are shown in
Outcome | Adjusted effect (SE) |
Mean difference (SEM) | 95% confidence interval of mean difference | |
---|---|---|---|---|
Severe dementia | 0.97 | −0.06 (1.72) | −3.43, 3.32 | |
Moderately severe dementia | <0.001 | 4.28 (1.16) | 2.01, 6.56 | |
Mild to moderate dementia | 0.54 | 1.11 (1.83) | −2.47, 4.69 | |
Severe dementia | 0.58 | −2.24 (4.05) | −10.17, 5.69 | |
Moderately severe dementia | 0.04 | −4.52 (2.17) | −8.77, −0.27 | |
Mild to moderate dementia | 0.05 | −4.57 (2.34) | −9.15, 0.01 | |
Severe dementia | 0.05 | −5.73 (2.90) | −11.42, −0.04 | |
Moderately severe dementia | 0.006 | −4.83 (1.75) | −8.26, −1.39 | |
Mild to moderate dementia | 0.13 | −3.05 (1.99) | −6.94, 0.84 |
*Adjusted effect takes into account baseline value, age, sex, Clinical Dementia Rating, site, and clustering within care homes.
CMAI, Cohen-Mansfield Agitation Inventory; NPI-NH, Neuropsychiatric Inventory–Nursing Home Version.
The sensitivity analysis using imputed values confirmed that WHELD conferred a statistically significant benefit in DEMQOL-Proxy (mean difference 0.06, 1.5 SEM;
A total of 549 serious adverse events were recorded during the period of the trial. The events were balanced between the 2 treatment groups, with no statistical differences (291 events in the WHELD group and 258 in the TAU group;
SAE category | Group | Total | |
---|---|---|---|
WHELD | TAU | ||
Dehydration | 8 | 2 | 10 |
Fall | 30 | 14 | 44 |
Fractures | 15 | 13 | 28 |
Mortality | 122 | 103 | 225 |
Pneumonia | 16 | 12 | 28 |
Stroke | 3 | 8 | 11 |
Delirium | 0 | 1 | 1 |
Chest infections | 26 | 15 | 41 |
Renal | 2 | 1 | 3 |
Increased confusion | 4 | 0 | 4 |
UTI | 11 | 7 | 18 |
Pulmonary embolism | 1 | 0 | 1 |
Other | 53 | 82 | 135 |
291 | 258 | 549 |
SAE, serious adverse event; TAU, treatment as usual; UTI, urinary tract infection.
The direct cost of delivering the intervention compared to TAU was £8,627 more per home. Fifty-three percent (£4,554) of the cost related to WHELD champion time spent in training and supervision. The remaining costs related to therapist time. Delivery of the intervention to residents incurred an additional £130 per person per month. The additional cost incurred for antipsychotic review was £23 per resident, which accounted for WHELD champion time spent reviewing antipsychotic use in 16% of residents and contacting prescribing physicians. Analysis of service use showed higher healthcare costs unrelated to the intervention in the TAU group compared to the WHELD intervention group. Participants receiving the intervention showed a significant health and social care cost advantage. Taking into account the cost of the intervention and the total health and social care costs, there was a cost advantage for the WHELD treatment (
Cost category | Intervention | TAU | Intervention versus TAU |
|||
---|---|---|---|---|---|---|
Mean (£) | SD (£) | Mean (£) | SD (£) | Unadjusted mean difference (£) | 95% CI | |
2,713 | 121 | 0 | — | 2,713 | 2,701 to 2,724 | |
Accommodation charges | 9,480 | 2,010 | 10,233 | 3,675 | −753 | −1,128 to −365 |
Hospital | 387 | 1,759 | 407 | 2,413 | −20 | 283 to 242 |
Primary care | 96 | 126 | 98 | 148 | −2 | 19 to 14 |
Community health | 23 | 80 | 19 | 79 | 4 | −7 to 14 |
Emergency | 12 | 37 | 9 | 34 | 3 | −1 to 7 |
Total health and social care costs | 9,998 | 2,601 | 10,766 | 4,396 | −768 | −1,249 to −338 |
Accommodation charges | 28,606 | 10,863 | 33,005 | 12,428 | −4,399 | −5,725 to −2,898 |
Hospital | 269 | 1,166 | 262 | 1,267 | 7 | −183 to 188 |
Primary care | 700 | 294 | 1,020 | 301 | −320 | −364 to −277 |
Community health | 78 | 260 | 70 | 206 | 8 | −23 to 44 |
Emergency | 49 | 133 | 85 | 244 | −36 | −68 to −10 |
Total health and social care costs | 29,702 | 8,774 | 34,442 | 11,106 | −4,740 | −6,129 to −3,156 |
*Cost comparisons for 9 months include covariates for site, age, baseline CMAI score, and baseline value of the same cost variable. Baseline cost comparisons include covariates for site, age, and baseline CMAI score.
CMAI, Cohen-Mansfield Agitation Inventory; TAU, treatment as usual.
In what is, to our knowledge, the largest RCT conducted of a staff training and non-pharmacological intervention for people with dementia living in nursing homes, we have demonstrated that the WHELD intervention confers a statistically significant improvement in QoL over 9 months. There was also a statistically significant benefit regarding agitation and overall neuropsychiatric symptoms over the 9-month period. Whilst the effect sizes were small, the benefits in agitation and neuropsychiatric symptoms were comparable to (agitation) or better than (NPI-NH) the benefits seen with antipsychotic drugs. There was also a significant increase in the proportion of positive care interactions between care staff and residents with dementia, with a moderate effect size. Importantly, the benefits were achieved in the context of a cost saving and used a model that can readily be implemented in nursing homes. Antipsychotic drug use was stable in both treatment groups across the study, and the WHELD treatment intervention did not reduce antipsychotic use (baseline frequency was very low).
Despite the importance of QoL, few trials have examined the impact of interventions on this outcome. In this study, the WHELD intervention conferred a statistically significant improvement in QoL over 9 months, building on a previous proof-of-concept study of WHELD. That study reported a reduction in QoL following antipsychotic review that was mediated by social interaction within the context of an overall PCC training paradigm for care staff [
Agitation is a frequent and distressing symptom for people with dementia living in nursing homes [
Although comparable to the effect sizes of atypical antipsychotics, the standardised effect sizes of benefit for WHELD were small in the context of a clinical intervention. The benefits did however include benefits in QoL, which have not been demonstrated with pharmacological interventions. Although there is no established threshold for a clinically meaningful benefit in QoL, any statistically significant benefit is important given the absence of any benefit in previous studies. In addition, the intervention was not just delivered to people with clinically significant neuropsychiatric symptoms, but conferred benefit amongst a broader population of people with dementia living in care homes. Whilst the effect sizes would be considered marginal in terms of a clinically significant benefit, we believe that the benefits to the broader population of people with dementia in care homes make this a meaningful benefit in the quality of care.
This study is consistent with the evidence base but provides important and novel data within the literature. Our results also compare favourably to those of the small number of published intervention studies that have focused on promoting PCC, none of which have reported benefits in QoL [
Elements of the WHELD intervention, such as social interaction and pleasant events, have previously been demonstrated to improve agitation in modest-sized RCTs [
Interestingly, there was a low baseline use of antipsychotic medications (<10%) in this study, reflecting the major changes in clinical practice and the reductions in antipsychotic use that have been achieved for people with dementia in the last decade. In contrast to our previous factorial RCT of the WHELD intervention, no significant reduction in antipsychotic use was achieved, and antipsychotic use was stable in both groups. This is likely attributable to a combination of the low baseline levels of antipsychotic prescription and the more limited education programme for primary care physicians within the current study than in the previous factorial RCT, and highlights the potential additional value of primary care education programmes in parallel to care home training.
This study was a robust, well-powered RCT evaluating the sustained impact of combining PCC and evidence-based non-pharmacological interventions for people with dementia in nursing homes. The study had good retention of surviving participants compared to most studies conducted in nursing home settings. The intervention evaluated was pragmatic, fully manualized, and designed so that it can be easily disseminated and implemented in routine clinical practice. There were also limitations. Antipsychotic review was based on augmenting processes within care homes to trigger medical review and did not in this study involve proactive primary care education. In addition, although the study used a well-validated method, evaluating QoL in people with dementia is challenging and all methods have some limitations. High mortality rates are usual in studies of frail groups of individuals living in care homes, but lead to high non-completion rates and present some challenges for data analysis and interpretation. One of the original secondary outcomes was to evaluate the impact of the intervention on the care home environment. The selected scale focused mainly on the physical building rather than other aspects of the environment, and the programme management group therefore decided to omit this measure at 9-month follow-up as it was unlikely that substantial building renovations had taken place in any of the participating care homes.
A key issue for future studies is the sustainability of the intervention, particularly with turnover of staff, including the WHELD champions. To be sustainable, the WHELD intervention needs to be firmly embedded within the care home culture, and it will be important for further research to identify the optimal approach to maintain benefits. As WHELD is largely verbally based, it will also be important to further evolve interventions more tailored to the needs of people with more severe dementia.
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In all, 847 participants were randomised, of whom 757 were included in the full imputation analysis.
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(DOCX)
AC and CB thank the National Institute for Health Research (NIHR) Biomedical Research Centre for Mental Health at South London and Maudsley NHS Foundation Trust and the Institute of Psychiatry, King’s College London and the NIHR Collaboration for Leadership in Applied Health Research and Care South West Peninsula for supporting their time for this work.
The views expressed are those of the authors and not necessarily those of the National Health Service, the NIHR, or the Department of Health.
analysis of covariance
Camberwell Assessment of Need for the Elderly
Clinical Dementia Rating
Cohen-Mansfield Agitation Inventory
Client Service Receipt Inventory
Cornell Scale for Depression in Dementia
Functional Assessment Staging Tool
Neuropsychiatric Inventory–Nursing Home Version
North Wales Organisation for Randomised Trials in Health Clinical Trial Unit
person-centred care
quality of life
Quality of Interactions Scale
randomised controlled trial
treatment as usual